marijuana support / key occupational employee license ... · notice: this marijuana occupational...

Marijuana Enforcement Division

Marijuana Support / Key Occupational Employee License Application

DR 8517 (02/21/18)

DR 8517 (02/21/18)

Colorado Marijuana Enforcement Division

Marijuana Support / Key Occupational Employee Application Instructions

APPLICATION CHECKLIST

1 License TypeNotice: You are required by state law to provide your social security number. If you do not have a social security number, you must complete a sworn statement stating you do not have a social security number. Support Employee: Any employee who does not act as a manager, supervisor or lead worker.Key Employee: Any manager, supervisor or lead worker, who acts as a Key employee or agent while physically working in a licensed Medical or Retail Marijuana BusinessMJ Workforce Development or Training Program: Must be enrolled in an approved training program or school. Residency may be waived for up to 2 years.

2 Application Completed & Signed–APPLICABLE DOCUMENTS MUST BE NOTARIZED PRIOR TO SUBMISSION TO THE MED

Type or clearly print an answer to every question. If a question does not apply, indicate with an N/A. If the available space is insufficient, continue on a separate sheet and precede each answer with the appropriate title. Sign and date the application. All Applications and documentation submitted must be single-sided and on 8.5x11 inch paper.

3 Proof of Identity/ResidencyYou MUST be a Colorado Resident at the time of application and be able to prove residency. You MUST provide a Colorado Driver's license or ID. (Unless enrolled in the MJ workforce or training program).

4 Application FeeSubmit the NON-REFUNDABLE application fee for a two-year license. See fee table on website: www.colorado.gov/revenue/med. Exact Cash, (only at the Lakewood office), check, or money order accepted. Make check or money order payable to: Colorado Department of Revenue (DOR)

5 Application SubmittalEmail the Lakewood office [email protected] for an appointment. Then bring in the application and all attachments at the time of your appointment:

Marijuana Enforcement Division1707 Cole Blvd., Suite 300Lakewood, CO 80401

ORCall the following office for an appointment:

Colorado Springs – (719) 570-5622Grand Junction – (970) 248-7181Longmont office – (303) 866-2274

NOTE: Incomplete applications WILL NOT be processed.

of 14

DR 8517 (02/21/18)COLORADO DEPARTMENT OF REVENUEMarijuana Enforcement Divisionwww.colorado.gov/revenue/med

Marijuana License Number (Leave Blank)

Marijuana Support / Key Occupational Employee License ApplicationPlease Check: Support Key Upgrade MJ Workforce Development or Training Program

Legal Last Name (Please Print) Legal First Name Full Legal Middle Name

Maiden/Married Names Used (Full Name) (Attach separate sheet if necessary)

Nicknames, Aliases, Etc. Used (Full Name) (Attach separate sheet if necessary)

Gender M F

Race Asian Black Caucasian Hispanic/Latino Mixed Race Native American Native Hawaiian/Pacific Islander Undisclosed/Unknown

Date of Birth Social Security Number Other Social Security Numbers Used

Yes No (If yes attach details.)

Place of Birth: City State Country Drivers License Number and State

Physical Appearance Height Weight Hair Color Eye Color

U.S. Citizen

Yes No*If "No", include details here: (Attach separate sheet if necessary)

Alien Registration Number CO Resident

Yes NoDate of CO Residency if not a CO resident, list

State resident of _____

Physical AddressAddress City County State ZIP

Length of time at this Address: Home Phone Number

( )Cell Phone Number

( )Email Address

Year(s) Month(s)

Mailing Address (if different from Physical Address)Address City State ZIP

List all addresses where you have lived during the last 5 years, not including present address, (attach separate sheet if necessary)

Street and Number City/State/ZIP From To

Licensed Marijuana business where you will be working (if known) Work Phone Number( )

Job Title

Name of present employer, if different from above Work Phone Number( )

Occupation or Job Title

Do you currently possess a Colorado Marijuana license (badge) to work in a Marijuana Business or are you an owner or associated person in any other type of Colorado Marijuana business?

Yes No *If "Yes", indicate license type and number here:Have you ever applied for a Marijuana license in this or any other jurisdiction, domestic or foreign, whether or not the license was ever issued? (Not including your Medical Marijuana patient card)

Yes No *If "Yes", explain here:Have you ever been denied a Marijuana license, withdrawn a Marijuana license application or had any disciplinary action taken against any Marijuana license that you have held, either individually or as part of an ownership group, in this or any other jurisdiction?

Yes No *If "Yes", explain here:Applicant's Signature Date

of 14

Applicant's Last Name (Please Print) First Name Full Middle Name

Notice: This Marijuana Occupational Employee Application Form is an official document. If you provide false information on your Marijuana license application, and/or do not disclose all information the application asks, your license is subject to denial, and you may be subject to criminal prosecution. The Marijuana Enforcement Division will conduct a complete background investigation and will check all sources of information. You are advised that it is better to disclose all information than face denial, revocation or criminal prosecution.

1. Have you discharged a sentence for a conviction of a felony pursuant to any state or federal law regarding the possession, distribution, manufacturing, cultivation, or use of a controlled substance, including probation or parole, within the past 10 years, even if the conviction occurred more than 10 years ago? (Unless charge was prior to age 18 and was adjudicated as a juvenile)

Yes No

2. Have you discharged a sentence, including probation or parole, within the past 5 years upon conviction for ANY felony, even if the conviction occurred more than 5 years ago? (Unless charge was prior to age 18 and was adjudicated as a juvenile)

Yes No

3. Have you failed to remedy an outstanding delinquency for any judgments, taxes, interest or penalties due to the Department of Revenue, relating to a Medical or Retail Marijuana Business?

Yes No

4. Are you a licensed Physician making marijuana patient recommendations? Yes No

5. Have you had your authority to act as a primary caregiver revoked by the State Health Agency? Yes No

6. Are you under 21 years of age at the time of this application? Yes No

7. Are you the spouse or child living in the household of any person employed by the Colorado Marijuana Enforcement Division?

Yes No

8. Are you a sheriff, deputy sheriff, police officer, or prosecuting officer, or an officer or employee with the marijuana state licensing authority or a local licensing authority?

Yes No

STOP! If you answered YES to any of the above questions, by Colorado law you cannot obtain or hold a Colorado Marijuana Occupational Employee license.

I have thoroughly read and understand the questions above, and understand that I cannot hold a Colorado Marijuana license if I answered “Yes” to any of the questions above.Applicant's Signature Date

of 14


Criminal History (DO NOT DISCLOSE CRIMINAL HISTORY WHERE NON-CONVICTION RECORD HAS BEEN SEALED OR EXPUNGED)1. In the last 10 years have you been arrested, served a criminal summons, charged with, or convicted

of ANY crime regarding the possession, distribution, manufacturing, cultivation or use of a controlled substance? (Unless charge was prior to age 18 and was adjudicated as a juvenile).

Yes No

2. In the last 5 years have you been arrested, served with a criminal summons, charged with, or convicted of ANY non-drug or non-narcotic related crime or offense in any manner in this or any other country?• You must include ALL arrests, charges, and convictions in the last 5 years (unless charge was

prior to age 18 and was adjudicated as a juvenile), regardless of the outcome, even if the charges were dismissed or you were found not guilty.

• You must include ALL arrests, charges, and convictions regardless of the class of crime (felonies, misdemeanors, and/or petty offenses).

• You must include ALL serious traffic offenses, including DUI; DWAI; reckless driving; leaving the scene of an accident (hit and run); driving under denial, suspension or revocation; or any other offense which resulted in your being taken into custody.

• NOTICE: Do not rely upon your understanding that an arrest or charge is “not supposed to be on your record.” A criminal record was not cleared, erased, sealed or expunged unless you were given, and have in your possession, a written order from a judge directing that action.

Yes No

*If you answered YES, explain in detail on pages 4 and 5 of this application, using additional sheets as necessary. For each FELONY offense for which you were arrested or charged, YOU MUST OBTAIN OFFICIAL DOCUMENTATION FROM THE COURT WHERE YOU APPEARED, SHOWING THE FINAL DISPOSITION (OUTCOME) OF YOUR CASE (FELONIES ONLY). This information will include whether you were found guilty or not guilty; the penalty (money fine, time in jail or prison, probation or deferred sentence). If you received a deferred judgment, a deferred sentence, or probation, your documentation must include the date that you were discharged or released from probation or other supervision.3. Have you ever received a pardon or its equivalent for any criminal offense in this or any other

country? Yes No

*If you answered YES to any of the preceding questions, explain in detail on a separate sheet and attach it to your application.

Applicant's Initials

of 14


Arrest Disclosure FormIn the last 10 years have you been arrested, served a criminal summons, charged with, or convicted of ANY crime regarding the possession, distribution or use of a controlled substance (unless charge was prior to age 18 and was adjudicated as a juvenile)? If so, you must disclose this information to the Marijuana Enforcement Division.If you have been arrested any where in the U.S., in the past 5 years, given a summons, or been convicted of any non-narcotic offense, you must disclose this information to the Marijuana Enforcement Division (dismissed charges sealed by the court do not need to be disclosed). If you have an outstanding warrant, you will be arrested at the time of application.Any person applying to be licensed by the Marijuana Enforcement Division, must make notification to the Division of any criminal conviction and/or criminal charge pending against such person. In addition to the above listed felonies, this list includes:

• Being taken into custody for any offense, including traffic offenses • Being issued a summons or citation for any offense except for minor traffic offenses • Failing to comply with your sentencing requirements• Failing to appear for a court proceeding and having a bench warrant issued• Having your driver’s license suspended or revoked• Being alleged to have driven under the influence or impairment of intoxicating liquor or drugs

Failure to disclose an arrest or citation may result in disciplinary action, up to and including the denial of your license application.

Please List Each Offense Separately

1 Date of Offense Place of Offense

Arresting Agency

Original Charge

Disposition Narrative — Must also provide official documentation (felonies only).


Arresting Agency

Original Charge


Signature Date

of 14


Arrest Disclosure Form(Continued)

Please List Each Offense Separately


Arresting Agency

Original Charge



Arresting Agency

Original Charge


Signature Date

of 14


1. Check any of the following privileged or professional licenses you have held individually or as part of an ownership group in this state or any other domestic or foreign jurisdiction:

Liquor Real Estate Broker/Sales Accountant Gaming Lawyer Physician Insurance Auto Industry Racing Lottery Securities Dealer Other:

None

2. Have you ever been denied a privileged or professional license, withdrawn a privileged or professional license application or had any disciplinary action (i.e.- denial, surrender, assurance of voluntary compliance, order to show cause, suspension, fine, revocation, stipulation or settlement, withdrawn or other penalties or sanctions.) taken against any such license that you have held, either individually or as part of an ownership group?

Yes No

3. Are you as an individual, principal of any form of business entity, or as an owner, officer or director of a corporation, delinquent in the payment of any judgments, taxes, interest or penalties due to the Department of Revenue, relating to a Medical or Retail Marijuana Business?

Yes No

*If you answered YES to any of the questions above or checked any boxes above, give details on separate sheet, including license number and dates license held for licenses marked on question 1. Include any items currently under formal dispute or legal appeal. Attach any documents to prove your settlement on any of these issues.

of 14

DR 4679 (03/24/14)COLORADO DEPARTMENT OF REVENUE

Affi davit - Restrictions On Public Benefi ts

I, ______________________________________________________________ , swear or affi rm under penalty of perjury under the laws of the State of Colorado that (check one):

I am a United States citizen.

I am not a United States citizen but I am a Permanent Resident of the United States.

I am not a United States citizen but I am lawfully present in the United States pursuant to Federal law.

I am a foreign national not physically present in the United States.

I understand that this sworn statement is required by law because I have applied for a public benefi t. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefi t. I further acknowledge that making a false, fi ctitious, or fraudulent statement or representation in this sworn affi davit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefi t is fraudulently received.

Signature Date (MM/DD/YY)

of 14

Affirmation & Consent

I, _______________________________________, state under Penalty for offering a false instrument for recording pursuant to 18-5-114 C.R.S. that the entire Support/Key Occupational Employee License Application Form, statements, attachments, and supporting schedules are true and correct to the best of my knowledge and belief, and that this statement is executed with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient cause for the refusal to issue a Marijuana license by the State Licensing Authority. Further, I am aware that later discovery of an omission or misrepresentation made in the above statements may be grounds for denial of the Marijuana application. I am voluntarily submitting this application to the Colorado Marijuana Licensing Authority under oath with full knowledge that I may be charged with perjury or other crimes for intentional omissions and misrepresentations pursuant to Colorado law or for offering a false instrument for recording pursuant to 18-5-114 C.R.S. I further consent to any background investigation necessary to determine my present and continuing suitability and that this consent continues as long as I hold a Colorado Marijuana license, and for 90 days following the expiration or surrender of such Marijuana license.Note: If your check is rejected due to insufficient or uncollected funds, the Department of Revenue may collect the payment amount directly from your banking account electronically.

Print your Full Legal Name clearly below:Legal Last Name (Please Print) Legal First Name Legal Middle Name

Signature Date

Marijuana Workforce Development or Training Program (complete only if applying for residency exemption)

In addition to the above affirmation, I, _______________________________________ further affirm, under the penalty of perjury, that I am currently enrolled in a Marijuana-Based Workforce Development or Training Program at the Licensed MJ Business or private occupational school (approved by the Colorado Dept. of Education) listed below.

Marijuana Entity (include Business License number, if known)

Address of Entity

Date of Enrollment Projected Completion Date

Name of Private Occupational School approved by the Colorado Dept. of Education

Address of School

Date of Enrollment Projected Completion Date

Confidential Document: This document is the property of the Colorado Marijuana State Licensing Authority and the Colorado Marijuana Enforcement Division, and is provided for Official Use Only. This document may not be further reproduced nor its contents disclosed without the written permission of the Division or State Licensing Authority.

of 14

Investigation Authorization/Authorization to Release InformationI, ____________________________________________________, hereby authorize the Colorado Marijuana Licensing Authority, the Marijuana Enforcement Division, (hereafter, the Investigatory Agencies) to conduct a complete investigation into my personal background, using whatever legal means they deem appropriate. I hereby authorize any person or entity contacted by the Investigatory Agencies to provide any and all such information deemed necessary by the Investigatory Agencies. I hereby waive any rights of confidentiality in this regard. I understand that by signing this authorization, a financial record check may be performed. I authorize any financial institution to surrender to the Investigatory Agencies a complete and accurate record of such transactions that may have occurred with that institution, including, but not limited to, internal banking memoranda, past and present loan applications, financial statements and any other documents relating to my personal or business financial records in whatever form and wherever located. I understand that by signing this authorization, a financial record check of my tax filing and tax obligation status may be performed. I authorize the Colorado Department of Revenue to surrender to the Investigatory Agencies a complete and accurate record of any and all tax information or records relating to me. I authorize the Investigatory Agencies to obtain, receive, review, copy, discuss and use any such tax information or documents relating to me. I authorize the release of this type of information, even though such information may be designated as “confidential” or “nonpublic” under the provisions of state or federal laws. I understand that by signing this authorization, a criminal history check will be performed. I authorize the Investigatory Agencies to obtain and use from any source, any information concerning me contained in any type of criminal history record files, wherever located. I understand that the criminal history record files contain records of arrests which may have resulted in a disposition other than a finding of guilt (i.e., dismissed charges, or charges that resulted in a not guilty finding). I understand that the information may contain listings of charges that resulted in suspended imposition of sentence, even though I successfully completed the conditions of said sentence and was discharged pursuant to law. I authorize the release of this type of information, even though this record may be designated as “confidential” or “nonpublic” under the provisions of state or federal laws.The Investigatory Agencies reserve the right to investigate all relevant information and facts to their satisfaction. I understand that the Investigatory Agencies may conduct a complete and comprehensive investigation to determine the accuracy of all information gathered. However, the State of Colorado, Investigatory Agencies, and other agents or employees of the State of Colorado shall not be held liable for the receipt, use, or dissemination of inaccurate information. I, on behalf of the applicant, its legal representatives, and assigns, hereby release, waive, discharge, and agree to hold harmless, and otherwise waive liability as to the State of Colorado, Investigatory Agencies, and other agents or employees of the State of Colorado for any damages resulting from any use, disclosure, or publication in any manner, other than a willfully unlawful disclosure or publication, of any material or information acquired during inquiries, investigations, or hearings, and hereby authorize the lawful use, disclosure, or publication of this material or information. Any information contained within my application, contained within any financial or personnel record, or otherwise found, obtained, or maintained by the Investigatory Agencies, shall be accessible to law enforcement agents of this or any other state, the government of the United States, or any foreign country.

Print Full Legal Name of Applicant clearly below:Last Name of Applicant (Please Print) First Name of Applicant Middle Name of Applicant

Applicant's Signature Date

State of ________________, County of ________________ Subscribed and sworn to (or affirmed)

before me this _______ day of __________________________, 20 ____, in _________________, (City)

___________________________, by ________________________________________________ (State) (Applicant's Printed Name)

Notary Seal

Signature of Notary Public

Printed Name of Notary Public

My Commission Expires


of 14

Applicant's Request to Release Information(All signatures must be notarized)

TO: (Leave Blank) FROM: (Applicant’s Printed Name)

1. I/We hereby authorize and request all persons to whom this request is presented having information relating to or concerning the above named applicant to furnish such information to a duly appointed agent of the Marijuana Enforcement Division whether or not such information would otherwise be protected from the disclosure by any constitutional, statutory or common law privilege.

2. I/We hereby authorize and request all persons to whom this request is presented having documents relating to or concerning the above named applicant to permit a duly appointed agent of the Marijuana Enforcement Division to review and copy any such documents, whether or not such documents would otherwise be protected from disclosure by any constitutional, statutory, or common law privilege.

3. I/We hereby authorize and request the Colorado Department of Revenue to permit a duly appointed agent of the Marijuana Enforcement Division to obtain, receive, review, copy, discuss and use any such tax information or documents relating to or concerning the above named applicant, whether or not such information or documents would otherwise be protected from disclosure by any constitutional, statutory, or common law privilege.

4. If the person to whom this request is presented is a brokerage firm, bank, savings and loan, or other financial institution or an officer of the same, I/we hereby authorize and request that a duly appointed agent of the Marijuana Enforcement Division be permitted to review and obtain copies of any and all documents, records or correspondence pertaining to me/us, including but not limited to past loan information, notes co-signed by me/us, checking account records, savings deposit records, safe deposit box records, passbook records, and general ledger folio sheets.

5. I/We do hereby make, constitute, and appoint any duly appointed agent of the Colorado Marijuana Enforcement Division, my/our true and lawful attorney in fact for me/us in my/our name, place, stead, and on my/our behalf and for my/our use and benefit:

(a) To request, review, copy sign for, or otherwise act for investigative purposes with respect to documents and information in the possession of the person to whom this request is presented as I/we might;

(b) To name the person or entity to whom this request is presented and insert that person’s name in the appropriate location in this request:

(c) To place the name of the agent presenting this request in the appropriate location on this request.6. I grant to said attorney in fact full power and authority to do, take, and perform all and every act and thing whatsoever

requisite, proper, or necessary to be done, in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as I/we might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that said attorney in fact, or his substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted.

7. This power of attorney ends twenty-four (24) months from the date of execution.8. The above named applicant has filed with the Colorado Marijuana Licensing Authority an application for

a Marijuana license. Said applicant understands that he/she is seeking the granting of a privilege and acknowledges that the burden of proving its qualifications for a favorable determination is at all times on the applicant. Said applicant accepts any risk of adverse public notice, embarrassment, criticism, or other action of financial loss, which may result from action with respect to this application.

9. I/We do, for myself/ourselves, my/our heirs, executors, administrators, successors, and assigns, hereby release, remise, and forever discharge the person to whom this request is presented, and his agents and employees from all and all manner or actions, causes of action, suits, debts, judgments, executions, claims, and demands whatsoever, known or unknown, in law or equity, which the applicant ever had, now has, may have, or claims to have against the person to whom this request is being presented or his agents or employees arising out of or by reason of complying with the request.

10. I/We agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees from and against all claims, damages, losses, and expenses, including reasonable attorneys’ fees arising out of or by reason of complying with this request.

11. A reproduction of this request by photocopying or similar process shall be for all intents and purposes as valid as the original.

Continued on next page

Applicant's Initials

of 14

Applicant's Request to Release Information(All signatures must be notarized)

Applicant's Last Name (Please Print) First Name Middle Name

Signature


before me this _______ day of ___________________________, 20 ___, in ___________________, (City)

___________________________, by __________________________________________________ (State) (Applicant's Printed Name)

Notary Seal




Spouse’s Last Name (Please Print) Spouse’s First Name Full Middle Name

Spouse’s Signature


before me this _______ day of ___________________________, 20 ___, in ___________________, (City)

___________________________, by __________________________________________________ (State) (Applicant's Printed Name)

Notary Seal





Continued from previous page

of 14

Dear Applicant

Thank you for your interest in becoming an Occupational license employee in the Marijuana industry. Before you submit your application, we want to make you aware of a few facts.

The Marijuana industry in Colorado is one of the most scrutinized businesses in the state, because Colorado citizens want the industry and everyone involved in it free from even the hint of any corruption or deceit. That’s why we take our regulation of the industry very seriously, including the issuance of licenses.

During the licensing process, we will conduct a thorough check of your background. If you pass our qualifications, you will be found suitable as an Occupational employee license holder that will allow you to work in the Marijuana industry. You should know that a Marijuana license is a privilege, not a right. One thing you must do to obtain this privilege, is be completely honest on your license application. The burden of proving qualifications for licensure, rests at all times with the applicant.

In particular, we ask you on page 3 of the application: “In the last 10 years have you been arrested, served a criminal summons, charged with, or convicted of ANY crime regarding the possession, distribution, or use of a controlled substance? (Unless charge was prior to age 18 and was adjudicated as a juvenile). In the past 5 years, but not prior to age 18 (unless charge was prior to age 18 and was adjudicated as a juvenile), have you been arrested, served with a criminal summons, charged with, or convicted of ANY crime or offense in any manner in this or any other country?” The application goes on to tell you to explain ALL such arrests or charges no matter the final outcome (dismissed charges sealed by the court do not need to be disclosed).

Did you list ALL arrests and charges required on page 4. This includes drug-related offenses and any other offenses in the last 10 years. Are you clear about what you need to disclose? If not, then ask someone at the front desk to assist you and answer any questions you might have. Here are some of the excuses we have heard from people who have failed to disclose arrests to us:

• My attorney told me I didn’t have to disclose.• I didn’t think I was arrested, because I only got a ticket/citation.• I didn’t think the arrest had anything to do with Marijuana.• I didn’t think that was still on my record.

If you have a conviction that resulted in your record being sealed or expunged, you must include the order from the judge. You have been informed throughout the application to disclose ALL arrests (except those non-convictions that were sealed or expunged). And you have just been informed again: You will not necessarily be denied a finding of suitability if you have ever been arrested, but you may be denied if you fail to disclose any arrest (unless it was sealed or expunged).

I have read and understand this letter.

Signed _______________________________________________________________ Date ________________

of 14

Marijuana Enforcement Division–Statement Of Understanding(Support/Key Occupational Employee)

(Initial each line below)

I understand I am responsible for knowing and complying with all state laws and regulations governing medical and retail marijuana pursuant to the Colorado Retail Marijuana Code, sections 12-43.4-101 et seq., C.R.S. (“Retail Code”) and the Colorado Medical Marijuana Code, sections 12-43.3-101 et seq., C.R.S. (“Medical Code”), as well as the rules promulgated thereunder pursuant to 1 CCR 212-1 and 1 CCR 212-2. I understand I am being made aware of the following laws and regulations and agree to comply with them, and all other applicable laws and regulations, upon issuance of my license:I understand I am required to notify the Denver office of the Marijuana Enforcement Division in writing, of any felony criminal charge and felony conviction against such person within ten days of my arrest or felony summons, and within ten days of the disposition of any arrest or summons. ______ (Rules M 231/R 231) I understand that I must pay a fee to obtain a duplicate license. ______ (Rules M 210/R 210)I understand I am required to renew my license prior to the expiration date of the license I am being issued. ______ (Rules M 203/R 203, M 252/R 252)I understand the Marijuana Enforcement Division does not mail out a renewal application and therefore I am responsible for obtaining and submitting a renewal application prior to the expiration date of the license I am being issued. ______ (Rules M 203/R 203, M 252/R 252)I understand if I allow my license to expire for even one day and then try to reapply, I must submit a new license application along with the new license application fee. ______ (Rules M 203/R 203, M 252/R 252)I understand if the Marijuana Enforcement Division contacts me regarding any issues associated with this license, I will provide any information the Marijuana Enforcement Division requests within 7 calendar days (unless otherwise instructed). ______ (Rules M 201/R 201)I understand that I must cooperate with employees and investigators of the Marijuana Enforcement Division who are conducting inspections or investigations relevant to the enforcement of laws and regulations related to the Medical and Retail Codes. ______ (Rules M 1202/R 1202) I understand I am responsible to notify the Marijuana Enforcement Division office in writing when I have a change in name, residence address, mailing address or phone number, since all correspondence is sent to my last known address. Failure to notify the Marijuana Enforcement Division could result in my not receiving my physical license, legal notices, and other correspondence. ______ (Rules M 250/R 250)I understand that I shall not by any means interfere with, obstruct or impede, the State Licensing Authority or employee or investigator of the Marijuana Enforcement Division, from exercising their duties pursuant to the provisions of the Medical and Retail Codes and all rules promulgated pursuant to it. ______ (Rules M 1202/R 1202)I understand that a license issued by the Marijuana Enforcement Division to Owners, Associated Keys/Persons and Occupational Licensees constitutes a revocable privilege. The burden of proving an Applicant’s qualifications for licensure rests at all times with the Applicant. ______ (Rules M 230/R 230/M 231.5/R 231.5)I understand in order to access or input data into the State’s Inventory Tracking System, I must possess a valid occupational license and agree to follow all the rules and guidelines set forth for the use of this system.______ (Rules M 233/R 233)I have read all of the above information and understand my responsibilities as a medical marijuana and/or retail marijuana licensee. I further understand that failure to comply with any law, regulation, or the provisions of this Statement, may result in criminal charges and/or may be grounds for disciplinary action including, but not limited to, the suspension or revocation of my license and a monetary penalty after an administrative hearing. Continued on next page.

of 14

Marijuana Enforcement Division–Statement Of Understanding(Support/Key Occupational Employee)

AffidavitLicensee’s Full Printed Name

Licensee’s Signature (Must sign in front of notary) Date


before me this _______ day of ___________________________, 20 ___, in _________________, (City)

___________________________, by ________________________________________________ (State) (Applicant's Printed Name)

Notary Seal



Notary Public, State of


marijuana support / key occupational employee license ... · notice: this marijuana occupational...

Documents